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Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http:// www.who.int/about/licensing. CONTENTS

Identify highly hazardous pesticides 25 Foreword 06 for withdrawal by using the criteria of the FAO/WHO Joint Meeting on Pesticide Management (JMPM) Glossary 08

Put in place regulatory actions to 26 Executive summary: 09 phase out, through national policies What pesticide registrars and enforcement, the most hazardous and regulators can do pesticides, alongside advice and training to prevent pesticide suicides about low-risk alternatives

Require data on human risk 26 Background 10 assessments for national registration of new pesticide products Suicide facts and figures 13 Facilitate the registration 26 and use of low-risk pesticides The disease burden from 13 pesticide self-poisoning Strengthen inspection and control 27 Risk factors for suicide 15 Be aware of the conflicting agendas 27 of different stakeholders Suicide methods 17 Support research into safer alternatives 27 Means restriction and suicide prevention 20 to highly hazardous pesticides

References 29 International conventions and United 22 Nations initiatives related to reducing reliance on use of pesticides Annexes 33

What pesticide registrars 24 Annex 1. Means restriction in a historical 33 and regulators can do to prevent context pesticide suicides Annex 2. Evidence of the impact of toxic 34 Identify pesticides commonly used 25 pesticide bans on suicides in fatal self-poisoning 6

FOREWORD

Suicide is a leading cause of premature mortality among young people in many countries, making it a serious global public health problem. Suicides are preventable but preventing them is no easy task. Interventions range from providing the best possible conditions for bringing up our children and young people, through accurate and timely assessment of mental disorders and their effective treatment, to responsible reporting of suicide by the media and the environmental control of risk factors.

Pesticide poisoning is one of the commonest, and most authorization and management of pesticides – whether readily preventable, methods of suicide in certain parts in a pesticide regulatory unit within a ministry, or in a of the world. Overall, pesticide poisoning accounts for dedicated pesticide registration authority or a member of as many as one in every five of the world’s suicides. a pesticide registration board. Appropriate action by pesticide registrars and regulators has the potential to save thousands of lives every year. WHO and FAO are particularly grateful to Professor David Gunnell, University of Bristol, United Kingdom of Great This booklet is one of a series of resources for specific Britain and Northern Ireland (UK), Professor Michael groups who are in a unique position to prevent deaths Eddleston, University of Edinburgh, UK, and Professor by suicide.1 Suicide prevention involves the concerted Flemming Konradsen, University of Copenhagen, efforts of many social sectors and professional groups – Denmark who produced the first version of this booklet national and local government, legislators, law enforcers, with inputs from Mark Davis, former team leader of health workers, educators, social agencies, the media, Pest and Pesticide management, Plant Production and families, schools, workplaces and communities. This Protection Division, Food and Agriculture Organization of resource is targeted at pesticide registrars and regulators the United Nations. who have an important role in reducing access to, and regulating the use of, highly hazardous pesticides. The text was subsequently reviewed by the following experts: Teresa Au, WHO headquarters, Geneva, Throughout the booklet “pesticide registrars and Switzerland; Lai Fong Chan, University Kebangsaan regulators” are referred to as a shorthand for all Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia; persons involved in the policy development, evaluation, Shu-Sen Chang, National Taiwan University, Taipei City,

1 See: : https://www.who.int/mental_health/resources/preventingsuicide/en/ (accessed 24 August 2019). Preventing suicide: a resource for pesticide registrars and regulators 7

China, Province of Taiwan; Christine Fuell, Food and Rome, Italy; Yongsheng Tong, Beijing Suicide Research Agriculture Organization of the United Nations (FAO), and Prevention Center, Beijing, China; Harold van der Valk, Rome, Italy; Jennifer Hall, WHO headquarters, Geneva, Chemicals and Health Branch, UN Environment, Geneva, Switzerland; Kairi Kolves, Australian Institute for Suicide Switzerland; Mark van Ommeren, WHO headquarters, Research and Prevention (AISRAP), Griffith University, Geneva, Switzerland; Danuta Wasserman, National Brisbane, Australia; Sandhya Kulshrestha, Central Centre for Suicide Research and Prevention of Mental Ill Insecticides Board and Registration Committee, Ministry Health (NASP), Karolinska Institutet, Stockholm, Sweden. of Agriculture and Farmers Welfare, Faridabad, India; Aiysha Malik, WHO headquarters, Geneva, Switzerland; David Bramley, Prangins, Switzerland, edited the text. Gamini Manuweera, Chemicals and Health Branch, UN Environment, Geneva, Switzerland; Matthew Miller, Bouvé This resource is being widely disseminated in the hope College of Health Sciences, Northeastern University, that it will be translated into local languages and adapted Boston (MA), United States of America; Oxana Perminova, to local situations. Such adaptation is a prerequisite for FAO, Rome, Italy; Jane Pirkis, University of Melbourne, its effectiveness. Comments and requests for permission Melbourne, Australia; Hanna-Andrea Rother, University to translate and adapt the resource are welcome. of Cape Town, South Africa; Elisabetta Tagliati, FAO,

Alexandra Fleischmann Rajpal Yadav Department of Mental Health and Substance Abuse Department of Control of Neglected Tropical Diseases World Health Organization World Health Organization

Richard Brown Baogen Gu Department of Public Health, Environmental Division of Plant Production and Protection and Social Determinants of Health Food and Agriculture Organization of the United Nations World Health Organization 8

GLOSSARY

HHP Highly hazardous pesticide HIC High-income country FAO Food and Agriculture Organization of the United Nations ILO International Labour Organization IPM Integrated pest management IVM Integrated vector management JMPM Joint Meeting on Pesticide Management (of FAO and WHO) LMIC Low- and middle-income countries UN United Nations UNEP United Nations Environment Programme (or UN Environment) WHO World Health Organization Preventing suicide: a resource for pesticide registrars and regulators 9

EXECUTIVE SUMMARY: WHAT PESTICIDE REGISTRARS AND REGULATORS CAN DO TO PREVENT PESTICIDE SUICIDES

Self-poisoning with pesticides causes up to one in five Pesticide registrars and regulators have a key role to of the world’s suicides. play in suicide prevention. Important approaches they can take include: Regulatory action in Bangladesh, the Republic of Korea, Sri Lanka and other countries indicates that » identifying the pesticides most commonly used in many suicide deaths can be prevented by bans on fatal self-poisoning specific pesticides. In Sri Lanka, for instance, bans are » identifying highly hazardous pesticides for thought to have led to 93 000 fewer suicide deaths withdrawal between 1995 and 2015. » taking regulatory actions to phase out the most hazardous pesticides, along with advice and There is no evidence that bans in these countries have training about low-risk alternatives adversely affected crop yields. » requiring data on human risk assessments, particularly in relation to acute toxicity when ingested, for national registration of new pesticide products » facilitating the registration and use of low-risk pesticides » strengthening inspection and other regulatory control » being aware of the conflicting agendas of different stakeholders » supporting research into safer alternatives to highly hazardous pesticides. 10

BACKGROUND

Pesticide registrars and regulators have a key role to WHO and the United Nations Environment Programme play in ensuring food security for their populations and (UNEP, or UN Environment) have shown the high cost in preventing vector-borne diseases. Their tools often to human health and the environment from continued include the use of chemical pesticides. Without these pesticide use (WHO & UNEP, 1990; UNEP, 2013). pesticides, food insecurity would have been greater and Furthermore, the International Labour Organization (ILO) the incidence of vector-borne disease higher over the recognizes the harms caused to farm workers who work last 70 years. However, pesticides are designed to be with highly hazardous pesticides (ILO, 2019). The FAO toxic to living organisms and are often not selective in Council has suggested that the actions of FAO could their toxicity. There is growing recognition of alternatives include pesticide risk reduction, including the progressive to intensive pesticide use – including integrated pest ban on highly hazardous pesticides (FAO, 2006). management (IPM) and integrated vector management (IVM) approaches as promoted by the World Health Vector control, if based on indoor residual spraying, Organization (WHO) and the Food and Agriculture is mainly carried out by large-scale government Organization of the United Nations (FAO) (FAO, 2016). programmes or, in some countries, private pest-control There is also growing awareness that sustainable crop agencies. However, in many farming communities around production is possible using agroecology. the world, agricultural pesticides are present in homes and workplaces, where they are used on both food and Over time, it has become evident that some pesticides non-food (e.g. cotton) crops as well as for grain storage. are extremely toxic to humans. Long-term occupational Pesticides are also commonly used in urban settings for or domestic exposure can result in chronic illnesses – household pest control; in some countries hazardous including dermatitis, respiratory problems and cancer, agricultural pesticides are commonly decanted into as well as reproductive, neurodevelopmental and unmarked containers and sold for domestic pest control behavioural disorders. Some pesticides cause acute (Rother, 2010). poisoning and have resulted in many deaths. In some cases, the acute toxic effects of pesticides are reversible Many people know others who have had suicidal thoughts if the right treatment is administered in time. In other or who have harmed themselves. WHO’s World Mental cases (e.g. paraquat and aluminium phosphide), no Health Surveys indicate that around 3% of people make effective treatment is available. a suicide attempt at some point in their lives (Nock et al., 2008). Risk factors for suicide are multifaceted and Preventing suicide: a resource for pesticide registrars and regulators 11

include factors that are psychological (e.g. depression), Prevention of pesticide suicides is relevant to achieving social (e.g. family conflicts), cultural (e.g. religious the United Nations Sustainable Development Goals views about suicide) and economic (e.g. poverty, debt, (SDGs) and indicators, such as: Goal 2 (End hunger, bankruptcy). Self-poisoning is the most frequently used achieve food security and improved nutrition and method for attempting suicide, and suicidal people often promote sustainable agriculture, with indicator 2.4.1 act impulsively by ingesting the most readily accessible on Proportion of agricultural area under productive and poison. In low- and middle-income countries (LMICs) sustainable agriculture) and Goal 3 (Ensure healthy lives this is often a pesticide (Eddleston, 2000; Mew et al., and promote well-being for all at all ages, with indicator 2017). The high toxicity of many pesticides means that 3.4.2 on reduction of suicide mortality rate). United such suicide attempts often lead to death, particularly in Nations Member States have committed to achieving the situations where medical facilities are far away or where SDGs and governments now need to ensure that these no effective treatment is available. goals are achieved by 2030.

Experience in some countries has shown that replacing This resource sets out the case for regulatory actions the agricultural pesticides that are most toxic to humans around highly hazardous pesticides with the aim of with less hazardous products significantly reduces deaths helping pesticide registrars and regulators in their work and illness from pesticide exposure without affecting of reducing deaths and illness associated with these agricultural yield (Gunnell et al., 2017; Manuweera et al., products, particularly in rural agricultural communities. 2008).

Pesticide registrars and regulators therefore have a major role in preventing suicides through such activities as strengthening the lifecycle management of pesticides – particularly requirement for data on risk assessment for product registration – phasing out highly hazardous pesticides, proper management of unused stocks in communities and households, and raising awareness about pesticide suicides. 12

Credit: WHO/Angeliki Antonia Balayannis Preventing suicide: a resource for pesticide registrars and regulators 13

SUICIDE FACTS AND FIGURES

It is estimated that close to 800 000 people die by suicide restricted or used only by professional sprayers using every year (WHO, 2019). Suicide is the second leading mechanized approaches. cause of death (after road injuries) in 15-29-year-olds worldwide and is one of the top 10 causes of death in Pesticides vary in their toxicity when ingested in acts many countries. Over three quarters (79%) of all suicides of self-poisoning (Box 1) (Dawson et al., 2010). The occur in LMICs (WHO, 2019). Each death by suicide herbicide paraquat, for instance, kills about half of all has devastating consequences for families, friends and people who ingest it, even in quantities as small as a communities. spoonful, whereas some of the new (less hazardous) pesticide products kill less than 1% of those who ingest For every person who dies by suicide around 20 people them. The relative toxicity of pesticides does not always make a suicide attempt (WHO, 2014). Many people who directly follow WHO’s classification of toxicity (WHO, attempt suicide are prevented from dying only because 2010) because this classification is mainly based on an of the availability of intensive care facilities and effective assessment of acute toxicity in rats after ingestion (i.e. treatments for some poisons. LD50 values – the dose that kills half of exposed animals), which is a standard parameter in toxicology. The disease burden from pesticide self- poisoning However, it is recognized that, in some cases, the acute hazard to humans may differ from the hazard indicated by

Between 110 000 and 168 000 pesticide self-poisoning LD50 assessments alone. For example, although research deaths (suicides) occur each year worldwide (Mew et (e.g. Dawson et al., 2010) has shown that the herbicide al., 2017). Since the 1950s, when the Green Revolution paraquat has an extremely high case fatality rate after brought highly hazardous pesticides into small-scale ingestion, it is classified as a WHO class II compound (i.e. farming, an estimated 14 million premature deaths have a moderately hazardous pesticide) on the basis of the 2 resulted from pesticide self-poisoning. Over 95% of LD50 value in rats. these deaths have occurred in LMICs. It is notable that self-poisoning deaths are lower in high-income countries (HIC) where highly hazardous pesticides are banned,

2 Karunarathne A, Gunnell D, Konradsen F, Eddleston M. How many premature deaths from pesticide suicides have occurred since the agricultural Green Revolution? Clin Toxicol (in press). 14

Box 1. Estimated case fatality rate of commonly-used pesticides (proportion of people who die following self-poisoning using each product)

PRODUCT CASE FATALITY

Herbicides

Paraquat 43-68%

Propanil 11%

MCPA (2-methyl-4-chlorophenoxyacetic acid) 5%

Glyphosate 2%

Rodenticides and fumigants

Aluminium phosphide 60-80%

Zinc phosphide 7%

Insecticides

Monocrotophos 35%

Parathion 25%

Endosulfan 22%

Dimethoate 20%

Fenthion 15%

Carbosulfan 11%

Chlorpyrifos 8%

Sources: Dawson et al., 2010; Azrael & Miller, 2016; Trakulsrichai et al., 2017. Preventing suicide: a resource for pesticide registrars and regulators 15

The pesticides most often ingested in fatal self-poisoning Suicide attempts often occur in the context of a short- vary from country to country, depending on the products lived life crisis such as family conflicts, the breakdown of a that are licensed and commonly used by farmers as well relationship or financial difficulties against a background as their toxicity. The pesticides that have accounted for of other factors that influence vulnerability. many deaths include paraquat, aluminium phosphide, highly toxic organochlorines (e.g. endosulfan, endrin), Although mental illness is a well-known risk factor for highly toxic organophosphorus insecticides (e.g. suicide, many people who attempt suicide do not have a phorate, methyl parathion, parathion, methamidophos, recognized mental health disorder and are not under the monocrotophos, dimethoate, fenthion) and carbamate care of health professionals. Indeed, it is often the suicide insecticides (e.g. aldicarb, carbofuran). attempt that first brings the person’s distress to the attention of those around them. If persons survive their While there are effective treatments for some forms of suicide attempt, they will usually go on to receive support pesticide poisoning if patients are treated early (e.g. from their family and community, as well as from mental atropine for carbamate and organophosphate insecticide health services if these are available. Those who die when poisoning, methylthioninium chloride for propanil they attempt suicide do not get a second chance. For this induced methaemoglobinaemia), many deaths occur reason, easy access to highly lethal suicide methods for before the person reaches hospital. Furthermore, there which there are no antidotes – such as pesticides – is a is no effective treatment for toxicity associated with key risk factor for suicide. consumption of some of the most toxic products, such as paraquat and aluminium phosphide. There are a number of common myths about suicide (Box 2). For instance, it is wrongly believed that those Risk factors for suicide who are determined to take their life will do so eventually; however, research shows that while a previous suicide Risk factors for suicide include mental illness, acute attempt is a strong risk factor for suicide, most people distress, poverty, breakdown of a marriage or relationship, who survive a suicide attempt do not go on to die by physical illness, job loss, exposure to violence, being suicide or even make a repeat attempt (Carroll, Metcalfe bullied or abused as a child, alcohol or drug abuse, a & Gunnell, 2014). If they survive, they usually go on to lead previous suicide attempt and access to high-lethality productive lives. suicide methods (WHO, 2014). A particular pressure for agricultural communities can be acute financial difficulties resulting from crop failure. 16

Box 2. Common myths about suicide and suicidal behaviour

Myth: Banning pesticides will have a serious impact on agricultural production and the 1 livelihood of low-income farmers Evidence indicates that selective bans on highly hazardous pesticides, along with promotion of suitable alternatives, does not influence crop yield (see Figure 2, Annex).

Myth: Only people with mental disorders are suicidal 2 Suicidal behaviour indicates deep unhappiness but not necessarily mental disorder. Many people living with mental disorders are not affected by suicidal behaviour, and not all people who take their own lives have a mental disorder.

Myth: If someone is determined to die there’s nothing that can be done to prevent it There is clear research evidence that many suicides are preventable using simple 3 approaches such as recognizing a person as being at risk and talking to them, and restricting access to highly lethal methods of suicide to buy time while suicidal feelings pass.

Myth: Once someone is suicidal, he or she will always remain suicidal 4 This is not true. Heightened suicide risk is often short-term and situation-specific. While suicidal thoughts may return, they are not permanent and a person with previously suicidal thoughts and attempts can go on to live a long life.

Myth: Someone who is suicidal is determined to die 5 On the contrary, suicidal people are often ambivalent about living or dying. Someone may act impulsively by drinking pesticides, for instance, and die a few days later, even though they would have liked to live. Access to emotional support at the right time, and preventing access to highly lethal methods of suicide, can prevent suicide.

Myth: You need to be a psychiatrist or health expert to prevent suicide 6 Government officials have a key role to play by removing or limiting access to the methods that people commonly use to attempt suicide. Anyone can help prevent suicides by looking out for early warning signs in other people and offering them help and by supporting friends, family members, co-workers and community members. Preventing suicide: a resource for pesticide registrars and regulators 17

Suicide methods The poison used in a suicide attempt depends to a large extent on what is most readily available during a moment Whether someone dies following a suicide attempt - i.e. of crisis (see Box 3 for three case histories). Research becomes a suicide - often depends on the method they from China and Sri Lanka shows that over half of people use. Worldwide, the three most common methods of who attempted suicide by drinking pesticides had planned suicide deaths are hanging, pesticide self-poisoning their act less than 30 minutes earlier, using whatever and firearms. The commonest method used in nonfatal poison was readily available in the house without regard suicide attempts is self-poisoning (Fleischmann et for toxicity (Eddleston et al., 2006; Jiang et al., 2013). al., 2005). There are differences between the most commonly used methods in deaths by suicide and the The potential suicide methods readily accessible to methods used in suicide attempts because the lethality someone in a moment of crisis therefore often play an of different methods varies. Hanging and firearms are important role in determining whether or not a person used relatively infrequently but, because of their high risk dies. A consistent body of research shows that restricting of death, they account for many suicides. In high-income access to high-lethality methods of suicide, such as countries, the poisons most frequently ingested in suicide highly hazardous pesticides (Konradsen et al., 2003), attempts by self-poisoning – pain killers, antidepressants saves lives (Mann et al.,2005; Zalsman et al., 2016). and tranquillizers – are relatively nontoxic and result in few deaths. In contrast, in LMICs, high-toxicity pesticides are often ingested, and some products have case fatality rates similar to those for suicide attempts by hanging and firearms.

Credit: WHO/TDR/Andy Craggs 18

Credit: Oulailax Nakhone/Shutterstock.com Preventing suicide: a resource for pesticide registrars and regulators 19

Box 3. Circumstances surrounding three cases of pesticide self-poisoning

CASE 1

A 15-year-old girl drank 20% paraquat after an argument and fight with her 11-year-old brother. She told the doctors treating her that she had not known that it was paraquat and in her distress had simply grabbed the nearest bottle in the house and drunk from it. She died two days later.

CASE 2

A 12-year-old boy presented in a coma after drinking 200 mL of chlorpyrifos (an organophosphorus pesticide). He was intubated and transferred to intensive care, where he was ventilated for 10 days. At discharge, he told the psychiatrist that he had drunk the pesticide in front of his alcohol- dependent father in an attempt to shock him and stop him hitting his mother. Seven years later, he was taking advanced level school examinations in mathematics.

CASE 3

A 52-year-old man drank 400 mL of 40% dimethoate while under the influence of alcohol. Neither his family nor his friends knew the reason for his act of self-harm. He was intubated and given oxygen, atropine, pralidoxime and dopamine. He died within 15 minutes.

Source: Eddleston & Phillips, 2004. 20

Means restriction and suicide prevention households, and local insecticide bans – have not shown clear evidence of effectiveness (Reifels et al., 2018; Knipe Research shows that changes in the availability of & Eddleston, 2019). highly lethal suicide methods may have an impact on a country’s overall suicide rates (see Figure 1) and may Means restriction in a historical context and evidence of save lives (Kreitman, 1976; Knipe et al., 2017). For this the impact of banning toxic pesticides on suicides are reason, WHO, the International Association of Suicide described in Annex 1 and Annex 2. Prevention (IASP) and leading suicide prevention experts recommend means restriction as one of the key effective interventions for the prevention of suicide (WHO, 2014).

For suicides by pesticide poisoning, regulations to ban the most toxic products are the most effective approach to reducing deaths (Gunnell et al., 2017). There is mixed evidence of the effectiveness of restricting sales to people for occupational use; if these restrictions cannot be enforced, as is the case in many countries, this will not reduce access to highly hazardous pesticides.

Alternative regulatory approaches, such as changes to pesticide product formulations or innovative packaging, have also been attempted but evidence for the effectiveness of these measures is limited. Studies that have looked at the impact of nonregulatory approaches to reducing pesticide suicides – such as non-pesticide agricultural management (e.g. farming using natural pesticides such as chillies), central storage facilities for pesticides, distribution of lockable storage containers to Preventing suicide: a resource for pesticide registrars and regulators 21

Figure 1. Incidence of suicide in Sri Lanka, 1880-2015

Crude Suicide rate per 100,000 60

50

40

30

20

10

0 1880 1885 1890 1895 1900 1905 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015

Down arrows show the timing of pesticide bans (1984 parathion, methylparathion; 1995: all remaining WHO class I pesticides; including methamidophos and monocrotophos, 1998: endosulfan; 2008: dimethoate, fenthion, paraquat). Suicide data were obtained from police records.

Source: Knipe, Gunnell & Eddleston, 2017. 22

INTERNATIONAL CONVENTIONS AND UNITED NATIONS INITIATIVES RELATED TO REDUCING RELIANCE ON USE OF PESTICIDES

International conventions have been developed to reduce without conditions, or to prohibit the import of chemicals the risks of highly hazardous chemicals, including listed in the treaty, and exporting countries are obliged to pesticides, to human health and the environment. Their make sure that producers within their jurisdiction comply. implementation is intended to lead to sound management When effectively implemented, the Convention prevents of chemicals, including agrochemicals, at all stages the export of a pesticide to a country without acceptance — including production, trade, transportation and use. from its national authorities. The Rotterdam Convention In the context of highly hazardous pesticides (HHPs), supports, in particular, developing countries and countries successful implementation of these conventions could, with economies in transition in, inter alia, identifying in addition to having wider benefits for human health and so-called severely hazardous pesticide formulations. the environment, greatly contribute to the prevention of These are chemicals formulated for pesticidal use that pesticide suicides. are known to produce severe health or environmental effects which are observable within a short period of time Rotterdam Convention after single or multiple exposure under conditions of use. While this can include lethal effects, intentional misuse There is increasing international momentum to stop of a pesticide, which would include use in suicide, is not the use of pesticides that are known to harm human within the scope of the Convention. Paraquat dichloride health and damage the environment. For instance, the formulations are on the agenda of the Conference of the Rotterdam Convention (1998) regulates international Parties to be considered for inclusion in the Convention’s trade in hazardous chemicals, including pesticides. Annex, thus increasing information exchange and shared Exporting countries must label products according to responsibilities among parties. This could in future international conventions and must inform importing contribute to a potential reduction of suicides with this countries of any known restrictions or bans. Parties easily available pesticide. to the Convention can decide whether to allow, with or Preventing suicide: a resource for pesticide registrars and regulators 23

Stockholm Convention 2. The United Nations Environment Programme (UNEP) hosts the Strategic Approach to International The objective of the Stockholm Convention is to protect Chemicals Management (SAICM) which calls for the human health and the environment from persistent promotion of alternatives to pesticides in order to organic pollutants. These pollutants include pesticides reduce and phase out highly hazardous pesticides.4 and are organic compounds that are resistant to environmental degradation, bioaccumulative and toxic. Reducing reliance on use of pesticides Once a pollutant is listed, the Stockholm Convention prohibits or severely restricts its production and use. One effective way of preventing pesticide suicides is to limit access to pesticides, and to HHPs in particular. International Code of Conduct of Pesticide Management This can be effectively achieved by reducing the reliance and the Strategic Approach to International Chemicals on pesticide for pest management. FAO promotes an Management (SAICM) Integrated approach to Pest Management known as IPM.5 This field-based approach is tailored to the specific needs Recent United Nations initiatives aimed at eliminating or of farmers. IPM emphasizes the growth of a healthy crop reducing the use of highly hazardous pesticides include with the least possible disruption to agro-ecosystems the following: and encourages natural pest-control mechanisms. It blends traditional or local knowledge with modern 1. The FAO/WHO International Code of Conduct on technology and limits the use of pesticides to situations Pesticide Management calls for highly hazardous where they are necessary and ensures that, when used, pesticides to be replaced with less harmful they are applied in the most efficient and effective way alternatives and the use of IPM and IVM. The Code possible with the aim of minimizing the impact on human includes guidelines on pesticide legislation and policy; health and the environment. One of the cardinal points of pesticide registration, compliance and enforcement; an IPM approach is that pesticides should be applied only distribution, sale and use; disposal of obsolete stock; as a last resort when there are no adequate non-chemical post-registration surveillance; and identification and alternatives and the use of pesticides is economically control of highly hazardous pesticides.3 justified.

3 See: http://www.fao.org/agriculture/crops/thematic-sitemap/theme/pests/code/list-guide-new/en/ (accessed 25 July 2019). 4 See: https://sustainabledevelopment.un.org/content/documents/SAICM_publication_ENG.pdf (accessed 25 July 2019). 5 IPM means the careful consideration of all available pest control techniques and subsequent integration of appropriate measures that discourage the development of pest populations, keep pesticides and other interventions to levels that are economically justified, and reduce or minimize risks to human and animal health and/or the environment. See: http://www.fao.org/agriculture/crops/thematic- sitemap/theme/pests/ipm/en/ (accessed 25 July 2019). 24

IPM programmes have demonstrated that it is possible to reduce pesticide use significantly without reducing WHAT PESTICIDE crop yield or farmer profits, even in areas with increased pressure from pests. Within regional IPM Farmer Field REGISTRARS AND School (FFS) programmes, pest reduction of 70% has been achieved on rice, cotton and vegetables. Some 10 REGULATORS CAN million farmers have so far been trained on IPM through FAO and the regional FFS programme in more than 95 DO TO PREVENT countries in Africa, Latin America, the Caribbean, Asia and Eastern Europe.6 PESTICIDE

In the field of vector control, the only pesticides which SUICIDES are considered to be highly hazardous pesticides that are currently recommended by WHO for malaria vector It is a key responsibility of regulators to give consideration control are DDT and clothianidin-based neonicotinoid to the health and environmental impacts of pesticides. In products. These should be applied within an IVM countries where regulatory decisions have been taken to approach. remove highly hazardous pesticides from use, viable and less hazardous products and approaches are available. These may cost less and be more sustainable.

Regulatory action can not only save many lives but also offers multiple benefits for agriculture. Such benefits include making farming safer, reducing risks of food contamination, conserving biodiversity that benefits farming by harbouring natural pest-control agents, and making agriculture more sustainable and resilient to the impacts of climate change. Actions for pesticide registrars and regulators include:

6 See: http://www.fao.org/farmer-field-schools/en/ (accessed 25 July 2019). Preventing suicide: a resource for pesticide registrars and regulators 25

Identify pesticides commonly used in fatal Identify highly hazardous pesticides for self-poisoning withdrawal by using the criteria of the FAO/WHO Joint Meeting on Pesticide Pesticide registrars and regulators should work closely Management (JMPM) with national poison centres (where these exist) and the public health units of ministries of health to carry out a Pesticide registrars and regulators should identify highly situation analysis to determine the number of deaths hazardous pesticides for withdrawal. The JMPM’s criteria and hospital admissions due to pesticide poisoning (FAO & WHO, 2016) for making these choices include: and to identify the specific pesticides and pesticide formulations most commonly involved. Particular • Criterion 1: all WHO class IA or class IB pesticides attention should be paid to those pesticides most often (WHO, 2010); ingested in self-poisoning (both in suicides and suicide • Criteria 5, 6 and 7: pesticide ingredients and attempts). Identification of these products may also formulations listed in the Stockholm Convention,7 be achieved through high-quality community, hospital Rotterdam Convention (FAO & UNEP, 2017) or and mortuary-based studies of a consecutive series of Montreal Protocol (UNEP, adopted 1987); pesticide suicide deaths or serious poisonings. Such • Criterion 8: pesticide active ingredients and studies should ideally be nationally representative, formulations that have shown a high incidence of covering the range of farming practices and settings severe or irreversible effects on human health or the (rural/urban). Further assessments every 3−5 years to environment (e.g. WHO class II pesticides with high assess the impact of regulatory action and changes in acute oral toxicity and high case fatality rates in self- the pesticides commonly used for suicide would bring harm, and toxic pesticides without a current antidote additional benefits. WHO has published guidance on or effective treatment). establishing surveillance systems for self-harm (WHO, 2016).

7 UNEP Stockholm Convention on Persistent Organic Pollutants (POPs). Pesticides listed in Annexes A and B. The criteria of what may constitute a POP are listed in Annex D. http://chm.pops.int/TheConvention/ThePOPs/ListingofPOPs/tabid/2509/Default.aspx (accessed 30 July 2019) 26

Put in place regulatory actions to phase out, effective antidotes exist to treat poisoning caused by a through national policies and enforcement, new pesticide, these should be clearly indicated on the the most hazardous pesticides, alongside product label. advice and training about low-risk alternatives The FAO has produced a toolkit to help pesticide regulators in the evaluation and authorization of Pesticide registrars and regulators should put in place pesticides in order to minimize the risks to human 8 regulatory actions to phase out, through national policies health and the environment. This, and advice and enforcement, the most hazardous pesticides from other relevant agencies, should be used to: (identified using the approaches and criteria outlined above) and in particular those frequently used for suicides. • inform the registration of new pesticide products; Such actions should be carried out along with provision • prevent the introduction of new highly hazardous of advice and training about low-risk pesticides or pesticides; alternatives through agricultural extension programmes • identify low-risk products that are effective, including (i.e. the education of farmers in agricultural practices) non-pesticide options for plant protection and pest based on scientific research findings and new knowledge. control. This will reduce the number of cases of poisoning and death not only from self-poisoning (suicide) but also from Facilitate the registration accidental and occupational poisoning. and use of low-risk pesticides Require data on human risk assessments for national registration of new pesticide Regulatory authorities can facilitate the registration and products use of low-risk pesticides in various ways. These can include differentiated registration fees (lower for low-risk products and higher for highly hazardous products), fast- The withdrawal of highly hazardous pesticides must tracking of the registration of low-risk (bio)pesticides, never be followed by the introduction of new, similarly provision of longer validity periods for registration of hazardous products. It is crucial that the registration of low-risk pesticides, and a reduced sales tax or subsidies new products should take into account their potential use on the production and sale of biopesticides. Regulation in suicide attempts and suicides, as well as other concerns of marketing and sales practices could also be used to such as carcinogenicity and other chronic toxicity. Where change demand for specific products.

8 See: http://www.fao.org/pesticide-registration-toolkit/en/ (accessed 25 July 2019). Preventing suicide: a resource for pesticide registrars and regulators 27

Strengthen inspection and control Right to Food criticized the “aggressive, unethical marketing tactics”9 (page 4) of the pesticides industry as well as the Many pesticide registrars and regulators not only money it spent on influencing policy makers and disputing evaluate and authorize pesticides but also enforce scientific evidence (Elver, 2017). Nevertheless, a dialogue pesticide legislation. Among other activities they conduct with industry may be helpful in identifying and promoting inspections and control pesticide importation, production, safer alternatives. sale and use. Banning or severely restricting a pesticide in a country may lead to illegal importation, production and It is essential to work closely with farmers, extension use, especially if the available alternatives are not (yet) officers and pesticide retailers to explain the rationale for the considered cost-effective by farmers or other pesticide withdrawal of commonly-used products and to advise that users. Without effective inspection and control, regulatory the use of low-risk alternatives is essential to ensure buy-in decisions may be undermined; effective enforcement is to any initiatives. therefore essential to ensure that regulatory decisions are in fact followed. Support research into safer alternatives to highly hazardous pesticides Regulatory activity should also include more effective policing of the sale and use of “street pesticides” — mixed Long-term research studies into the most cost-effective and unlabelled cocktails commonly sold in a number of safer alternatives to the use of highly hazardous pesticides countries. Risks associated with these mixtures include are needed. Such studies should be carried out from exposure during handling, transportation, and storage economic, health and agricultural perspectives. Studies in people’s homes in containers with little or no safety should be carried out independently of industry and require information. the collaboration of the Ministry of Agriculture and farmers, as well as of the Ministry of Health. Be aware of the conflicting agendas of different stakeholders

It is important for pesticide registrars and regulators to be aware of the different interests of stakeholders in the pesticide industry and among users of pesticides. A report by the United Nations Special Rapporteur on the

9 See: https://reliefweb.int/report/world/report-special-rapporteur-right-food-ahrc3448 (accessed 25 July 2019), p. 4 28

Credit: WHO Preventing suicide: a resource for pesticide registrars and regulators 29

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• Trakulsrichai S, Kosanyawat N, Atiksawedparit P, • WHO (2016). Practice manual for establishing Sriapha C, Tongpoo A, Udomsubpayakul U et al. (2017). and maintaining surveillance systems for suicide Clinical characteristics of zinc phosphide poisoning attempts and self-harm. Geneva: World Health in Thailand. Ther Clin Risk Manag.13:335–40. Organization (http://www.who.int/mental_health/ • UNECE (2019). Globally Harmonized System of suicide-prevention/attempts_surveillance_systems/ Classification and Labelling of Chemicals (GHS). en/, accessed 26 July 2019). Geneva: United Nations Economic Commission for • Zalsman G, Hawton K, Wasserman D, van Heeringen Europe (https://www.unece.org/trans/danger/publi/ K, Arensman E, Sarchiapone M et al. Suicide ghs/ghs_welcome_e.html, accessed 26 July 2016). prevention strategies revisited: 10-year systematic • UNEP Montreal Protocol, adopted 15 September review. Lancet Psychiatry. 2016;3(7):646-59. 1987. Nairobi: United Nations Environment Programme (https://www.unenvironment.org/ ozonaction/who-we-are/about-montreal-protocol, accessed 2 June 2019). • UNEP (2013). Global chemicals outlook: towards sound management of chemicals. Geneva: United Nations Environment Programme. • WHO, UNEP (1990). Public health impact of pesticides used in agriculture. Geneva & Nairobi: World Health Organization & United Nations Environment Programme (https://apps.who.int/iris/ handle/10665/39772, accessed 26 July 2019). • WHO (2010). The WHO recommended classification of pesticides by hazard and guidelines to classification 2009. Geneva: World Health Organization. https:// www.who.int/ipcs/publications/pesticides_ hazard_2009.pdf?ua=1, accessed 26 July 2019). • WHO (2014). Preventing suicide: a global imperative. Geneva: World Health Organization. • WHO (2019). World Health Statistics 2019: monitoring health for the SDGs. Geneva: World Health Organization (https://www.who.int/gho/ publications/world_health_statistics/2019/en/, accessed 30 May 2019). 32

Credit: WHO/TDR/Andy Craggs Preventing suicide: a resource for pesticide registrars and regulators 33

ANNEXES

Annex 1: Means restriction in a historical There are many other examples of the impact of the easy context availability of suicide methods on suicide rates. In the USA, for example, variations between states in the levels Detoxification of Britain’s domestic gas supply in the of household firearm ownership are strongly associated 1960s had a dramatic impact on suicide rates. At that with both rates of suicide by guns and overall (all-method) time, domestic gas poisoning was the most common suicide rates (Miller et al., 2013). In Australia, regulations method of suicide among men and women. When Britain restricting the prescribing of barbiturates − a commonly- changed its gas supply from toxic coal gas (with a high used method of suicide in the 1960s − led to reductions carbon monoxide content) to relatively harmless natural in suicides (Oliver & Hetzel, 1972). gas, the suicide rate by gassing fell. People did not generally revert to other (more lethal) methods of suicide There is now a growing body of international evidence (such as shooting, pesticide ingestion or hanging), so indicating that regulations to prohibit the use of highly overall suicides fell by some 20−30% (Kreitman, 1976) hazardous pesticides can lead to reductions in national . suicide rates (see Annex 2). In the 1980s and 1990s, Sri Lanka had one of the highest suicide rates in the world. This was thought to be due chiefly to the ready availability and unregulated use of highly hazardous (WHO Class I) and other pesticides by small-scale farmers. Suicides by pesticide poisoning accounted for two thirds of all suicides in Sri Lanka at that time. Regulatory action taken in the mid-1990s to ban or severely restrict the pesticides responsible for most deaths resulted in a 70% drop in deaths by any form of suicide over the ensuing 20 years (Knipe, Gunnell & Eddleston, 2017). In contrast, the introduction of one of the highest lethality pesticides – paraquat – into Western Samoa in the 1970s was followed by a large rise in pesticide suicide and overall suicide deaths (Bowles, 1995). 34

Annex 2: Evidence of the impact of toxic 2016). Bans of highly hazardous pesticides in Bangladesh pesticide bans on suicides in the early 2000s resulted in a 65% reduction in pesticide suicides (Chowdhury et al., 2018). In several countries, ministries of agriculture have introduced regulations on specific pesticides or classes An estimated 35 000 fewer people died from pesticide of pesticides. Researchers have studied the impact of suicides between 2001 and 2014 compared to the such pesticide bans on suicide rates and crop yields. number predicted on the basis of earlier trends before the bans. Importantly, in Bangladesh, the Republic of The best-studied country is Sri Lanka, where a series of Korea and Sri Lanka, no impact of the pesticide bans on bans over a period of approximately 20 years led to a crop yield has been detected. Figure 2 shows trends in 70% fall in suicides and an estimated 93 000 lives saved rice production in Sri Lanka since the 1950s. Production between 1995 and 2015 (Figure 1). These reductions has increased since the 1990s when the first bans were in suicide occurred despite increases in the number introduced. of hospital admissions for pesticide self-poisoning during this period. Because the pesticides that people A recent review of the worldwide literature found were ingesting were less toxic, fewer people died. The evaluations of Ministry of Agriculture bans and/or bans were put in place in a stepwise way. Following regulations in 16 countries – five LMICs (Bangladesh, the bans, local data were supplied to policy-makers on Colombia, India, Jordan and Sri Lanka), and 11 high-income the impact of each ban and on changes in the specific countries (Denmark, Finland, Germany, Greece, Hungary, pesticide products that subsequently contributed to the Ireland, Japan, Republic of Korea, Taiwan [China], United greatest number of suicides. These data contributed to Kingdom, United States of America) (Gunnell et al., 2017). subsequent regulatory initiatives. Bans were the most effective approach: in five of the six countries where the impact of bans was evaluated, the In the Republic of Korea – where paraquat accounted for bans were followed by reductions in pesticide suicides the majority of pesticide suicide deaths in the 2000s – a and, in three countries, falls in overall suicides. ban on paraquat in 2011-2012 was followed by a halving of suicide deaths from pesticide poisoning between 2011 There was mixed evidence in the review that restricting and 2013; the ban is thought to have contributed to half sales to people for occupational use was effective. of the fall in overall suicides over these years (Cha et al., No studies reliably showed that such restrictions led Preventing suicide: a resource for pesticide registrars and regulators 35

to reductions in overall suicides (all methods). The authors of the review concluded that a worldwide ban on the use of highly hazardous pesticides was likely to prevent tens of thousands of deaths every year.

Other approaches to reducing suicide by pesticide poisoning

A small number of studies have looked at the impact of nonregulatory approaches to reducing pesticide suicides. These measures include non-pesticide agricultural management, central storage facilities for pesticides, distribution of lockable storage containers for households, and local insecticide bans (Reifels et al., 2018; Knipe & Eddleston, 2019). In most cases the studies were pilots and were too small in scale to provide statistically reliable results. For example, in safer storage pilots of lockable boxes or central storage where access was provided via a facility keeper/key-holder, success was limited because the majority of pesticide users chose to continue storing their pesticides at home or in the fields (Reifels et al., 2018). The one randomized controlled trial that was large enough in scale (180 villages with 223 000 people taking part) to test the effectiveness of lockable household pesticide storage containers found no evidence of effectiveness (Pearson et al., 2017). By the end of the study only half of all households still stored their pesticides in locked containers, indicating that this was not a sustainable approach. 36

Figure Trends2. Trends in rice paddsin rice production paddy in production Sri Lanka between in Sri 1951/2 Lanka, and 2017/18. 1951/52 Suource: to 2017/18 Ministry of Agriculture Statistics 100 Trends in rice padds production in Sri Lanka between 1951/2 and 2017/18. Suource: Ministry of Agriculture Statistics 90 100

80 90 80 70 70 60 60 50 50 40 40

30 30

20 20

10 10

0 0 1951/52 1953/54 1955/56 1957/58 1959/60 1961/62 1963/64 1965/66 1967/68 1969/70 1971/72 1973/74 1975/76 1977/78 1979/80 1981/82 1983/84 1985/86 1987/88 1989/90 1991/92 1993/94 1995/96 1997/98 1999/00 2001/02 2003/04 2005/06 2007/08 2009/10 2011/12 2013/14 2015/16 2017/18 1951/52 1953/54 1955/56 1957/58 1959/60 1961/62 1963/64 1965/66 1967/68 1969/70 1971/72 1973/74 1975/76 1977/78 1979/80 1981/82 1983/84 1985/86 1987/88 1989/90 1991/92 1993/94 1995/96 1997/98 1999/00 2001/02 2003/04 2005/06 2007/08 2009/10 2011/12 2013/14 2015/16 2017/18 Maha season: Bushels/Acre Yala season: Bushels/acre Maha season: Bushels/Acre Yala season: Bushels/acre

Down arrows show the timing of pesticide bans (1984 parathion, methylparathion; 1995: all remaining WHO class I pesticides; including methamidophos and monocrotophos, 1998: endosulfan; 2008: dimethoate, fenthion, paraquat). Suicide data were obtained from police records.

Source: Ministry of Agriculture statistics (http://www.statistics.gov.lk/agriculture/Paddy%20Statistics/PaddyStats.htm, accessed 13 May 2019). CA6027EN